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Mayur Sharma, Beatrice Ugiliweneza, Zaid Aljuboori and Maxwell Boakye

OBJECTIVE

Opioid abuse is highly prevalent in patients with back pain. The aim of this study was to identify health care utilization and overall costs associated with opioid dependence in patients undergoing surgery for degenerative spondylolisthesis (DS).

METHODS

The authors queried the MarketScan database using ICD-9 and CPT-4 codes from 2000 to 2012. Opioid dependency was defined as having a diagnosis of opioid use disorder, having a prescription for opioid use disorder, or having 10 or more opioid prescriptions. Opioid dependency was evaluated in 12-month period leading to surgery and in the period 3–15 months following the procedure. Patients were segregated into 4 groups based on opioid dependence before and after surgery: group NDND (prior nondependent who remain nondependent), group NDD (prior nondependent who become dependent), group DND (prior dependent who become nondependent), and group DD (prior dependent who remain dependent). The outcomes of interest were discharge disposition, hospital length of stay (LOS), complications, and health care resource costs. The 4 groups were compared using the Kruskal-Wallis test and linear contrasts built from generalized regression models.

RESULTS

A total of 10,708 patients were identified, with 81.57%, 3.58%, 8.54%, and 6.32% of patients in groups NDND, NDD, DND, and DD, respectively. In group DD, 96.31% of patients had decompression with fusion, compared with 93.59% in group NDND. Patients in group NDD, DND, and DD had longer hospital LOS compared with those in group NDND. Patients in group DD were less likely to be discharged home compared with those in group NDND (odds ratio 0.639, 95% confidence interval 0.52–0.785). At 3–15 months postdischarge, patients in group DD incurred 21% higher hospital readmission costs compared with those in group NDND. However, patients in groups NDD and DD were likely to incur 2.8 times the overall costs compared with patients in group NDND (p < 0.001) at 3–15 months after surgery (median overall payments: group NDD $20,033 and group DD $19,654, vs group NDND $7994).

CONCLUSIONS

Patients who continued to be opioid dependent or became opioid dependent following surgery for DS incurred significantly higher health care utilization and costs within 3 months and in the period 3–15 months after discharge from surgery.

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Anil Nanda, Sudheer Ambekar, Vijayakumar Javalkar and Mayur Sharma

Object

Tuberculum sellae meningiomas (TSMs) and diaphragma sellae meningiomas (DSMs) are challenging lesions to treat due to their proximity to neurovascular structures.

Methods

The authors reviewed the medical records of patients who underwent surgical excision of TSMs and DSMs from 1990 to 2013. They also describe the technical strategies used to minimize injury to the optic apparatus, vascular structures, and pituitary stalk.

Results

Twenty-four patients with TSM and 6 patients with DSM were included in the study. Seventy percent of the tumors were large (≥ 5 cm). The pterional approach was employed in most cases. Optic canal involvement was observed in 4 patients. Twenty-one patients (70%) had visual dysfunction before surgery. At follow-up (median 18 months), visual improvement was noted in 10 (47.6%) of 21 patients. Gross-total excision was achieved in 22 patients (91.6%) with TSM and 5 (83.3%) with DSM. At last follow-up, 28 patients (93.3%) had a Glasgow Outcome Scale score of 5. There were no deaths in this series.

Conclusions

Tuberculum and diaphragma sellae meningiomas present a unique subset of tumors due to their location. They can be safely excised with minimal morbidity and mortality using microsurgical techniques. Attention to technical details during surgery leads to greater respectability and superior visual outcome.

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Sunil Kukreja, Sudheer Ambekar, Mayur Sharma and Anil Nanda

The authors report the case of a spinal intradural schwannoma presenting with intracranial subarachnoid hemorrhage (SAH). Cerebral angiography did not show any intracranial lesion; however, MRI revealed two separate tumors in the lower segment of the spinal cord. The proximal lesion arising from the conus medullaris was well circumscribed and homogeneously enhanced, whereas the tumor in the cauda equina revealed hemorrhagic signals on MRI. This case also illustrates an unusual presentation of intracranial SAH simultaneously with intratumoral hemorrhage in a spinal cord schwannoma. The absence of hemorrhagic changes in the lesion arising proximal to the cauda equina region supports the mechanical theory proposed for the pathogenesis of hemorrhagic complications in spinal cord tumors.

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Mayur Sharma, Pooja SirDeshpande, Beatrice Ugiliweneza, Nicholas Dietz and Maxwell Boakye

OBJECTIVE

Symptomatic perineural or Tarlov cysts (TCs) are a rare cause of chronic low-back pain. Given the rarity of the disease, there is no literature consensus regarding the optimal management of these cysts.

METHODS

The authors conducted a systematic comparative outcome analysis of symptomatic TCs treated with surgery (group A, 32 studies, n = 333) or percutaneous interventions (group B, 6 studies, n = 417) analyzing the demographic characteristics, baseline characteristics of the cysts, clinical presentations, types of interventions, complication rates, and the recurrence rate in both treatment groups. The literature search was performed using the PubMed, MEDLINE, Cochrane, and Ovid databases up to 2018. The MeSH search terms used were “Tarlov cyst,” “sacral perineural cyst,” “sacral nerve root cyst,” “meningeal cyst of the sacral spine,” “extra meningeal cyst with spinal nerve root fibers,” “spinal extradural arachnoid pouch,” and “cyst of the sacral nerve root sheath.” The authors used statistical tests for two proportions using the “N-1” chi-square test with the free version of MedCalc for Windows for comparison among the groups.

RESULTS

Overall symptomatic improvement was reported in 83.5% of patients in both groups; however, exacerbation of preprocedural symptoms was significantly higher in group B than group A (10.1% vs 3.3%, p = 0.0003). The overall complication rates in the surgical and nonsurgical groups were 21% and 12.47%, respectively. Transient sciatica was the most common complication in both groups (17% vs 8%, respectively; p = 0.017). The incidence of cyst recurrence was much lower in group A than group B (8% vs 20%, p = 0.0018). The mean follow-up duration for the surgical group was 38 ± 29 months (25 studies, n = 279), while that for the nonsurgical group was 15 ± 12 months (4 studies, n = 290) (p < 0.0001).

CONCLUSIONS

The authors noted that although the surgical interventions were associated with higher postprocedural complication rates, long-term efficacy and success in terms of cyst resolution were superior following surgery compared to percutaneous procedures in the management of symptomatic TCs. There was no difference in symptom recurrence with either of the techniques.

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Mayur Sharma, Tyler Ball, Ahmad Alhourani, Beatrice Ugiliweneza, Dengzhi Wang, Maxwell Boakye and Joseph S. Neimat

OBJECTIVE

Surgery for medically refractory epilepsy (RE) is an underutilized treatment modality, despite its efficacy. Laser interstitial thermal therapy (LITT), which is minimally invasive, is increasingly being utilized for a variety of brain lesions and offers comparable seizure outcomes. The aim of this study was to report the national trends of open surgical procedures for RE with the advent of LITT.

METHODS

Data were extracted using the ICD-9/10 codes from the Nationwide Inpatient Sample (NIS, 2012–2016) in this retrospective study. Patients with a primary diagnosis of RE who underwent either open surgeries (lobectomy, partial lobectomy, and amygdalohippocampectomy) or LITT were included. Patient demographics, complications, hospital length of stay (LOS), discharge disposition, and index hospitalization costs were analyzed. Propensity score matching (PSM) was used to analyze outcomes.

RESULTS

A cohort of 128,525 in-hospital patients with RE was included and 5.5% (n = 7045) of these patients underwent either open surgical procedures (94.3%) or LITT (5.7%). LITT is increasingly being performed at a rate of 1.09 per 1000 epilepsy admissions/year, while open surgical procedures are decreasing at a rate of 10.4/1000 cases/year. The majority of procedures were elective (92%) and were performed at large-bed-size hospitals (86%). All LITT procedures were performed at teaching facilities and the majority were performed in the South (37%) and West (30%) regions. The median LOS was 1 day for the LITT cohort and 4 days for the open cohort. Index hospitalization charges were significantly lower following LITT compared to open procedures ($108,332 for LITT vs $124,012 for open surgery, p < 0.0001). LITT was associated with shorter median LOS, high likelihood of discharge home, and lower median index hospitalization charges compared to open procedures for RE on PSM analysis.

CONCLUSIONS

LITT is increasingly being performed in favor of open surgical procedures. LITT is associated with a shorter LOS, a higher likelihood of being discharged home, and lower index hospitalization charges compared to open procedures. LITT is a safe treatment modality in carefully selected patients with RE and offers an opportunity to increase the utilization of surgical treatment in patients who may be opposed to open surgery or have contraindications that preclude open surgery.

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Mayur Sharma, Sudheer Ambekar, Bharat Guthikonda, Jessica Wilden and Anil Nanda

Object

The aim of this study was to analyze the incidence of adverse outcomes, complications, inpatient mortality, length of hospital stay, and the factors affecting them between academic and nonacademic centers after deep brain stimulation (DBS) surgery for Parkinson's disease (PD). The authors also analyzed the impact of various factors on the total hospitalization charges after this procedure.

Methods

This is a retrospective cohort study using the Nationwide Inpatient Sample (NIS) from 2006 to 2010. Various patient and hospital variables were analyzed from the database. The adverse discharge disposition and the higher cost of hospitalization were taken as the dependent variables.

Results

A total of 2244 patients who underwent surgical treatment for PD were identified from the database. The mean age was 64.22 ± 9.8 years and 68.7% (n = 1523) of the patients were male. The majority of the patients was discharged to home or self-care (87.9%, n = 1972). The majority of the procedures was performed at high-volume centers (64.8%, n = 1453), at academic institutions (85.33%, n = 1915), in urban areas (n = 2158, 96.16%), and at hospitals with a large bedsize (86.6%, n = 1907) in the West or South. Adverse discharge disposition was more likely in elderly patients (OR > 1, p = 0.011) with high comorbidity index (OR 1.508 [95% CI 1.148–1.98], p = 0.004) and those with complications (OR 3.155 [95% CI 1.202–8.279], p = 0.033). A hospital with a larger annual caseload was an independent predictor of adverse discharge disposition (OR 3.543 [95% CI 1.781–7.048], p < 0.001), whereas patients treated by physicians with high case volumes had significantly better outcomes (p = 0.006). The median total cost of hospitalization had increased by 6% from 2006 through 2010. Hospitals with a smaller case volume (OR 0.093, p < 0.001), private hospitals (OR 11.027, p < 0.001), nonteaching hospitals (OR 3.139, p = 0.003), and hospitals in the West compared with hospitals in Northeast and the Midwest (OR 1.885 [p = 0.033] and OR 2.897 [p = 0.031], respectively) were independent predictors of higher hospital cost. The mean length of hospital stay decreased from 2.03 days in 2006 to 1.55 days in 2010. There was no difference in the discharge disposition among academic versus nonacademic centers and rural versus urban hospitals (p > 0.05).

Conclusions

Elderly female patients with nonprivate insurance and high comorbidity index who underwent surgery at low-volume centers performed by a surgeon with a low annual case volume and the occurrence of postoperative complications were correlated with an adverse discharge disposition. High-volume, government-owned academic centers in the Northeast were associated with a lower cost incurred to the hospitals. It can be recommended that the widespread availability of this procedure across small, academic centers in rural areas may not only provide easier access to the patients but also reduces the total cost of hospitalization.

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Mayur Sharma, Ghaith Habboub, Mandana Behbahani, Danilo Silva, Gene H. Barnett and Alireza M. Mohammadi

OBJECTIVE

Laser interstitial thermal therapy (LITT) has been increasingly used to treat deep-seated tumors. Despite its being minimally invasive, there is a risk of LITT damaging adjacent critical structures, including corticospinal tracts (CSTs). In this study, the authors investigated the predictive value of overlap between the hyperthermic field and CSTs in determining postoperative motor deficit (PMDs).

METHODS

More than 140 patients underwent an LITT procedure in our institution between April 2011 and June 2015. Because of the tumor's proximity to critical structures, 80 of them underwent preoperative diffusion tensor imaging and were included in this study. Extent of the hyperthermic field was delineated by the software as thermal-damage-threshold (TDT) lines (yellow [43°C for 2 minutes], blue [43°C for 10 minutes], and white [43°C for 60 minutes]). The maximum volume and the surface area of overlaps between motor fibers and the TDT lines were calculated and compared with the PMDs.

RESULTS

High-grade glioma (n = 46) was the most common indication for LITT. Postoperative motor deficits (partial or complete) were seen in 14 patients (11 with permanent and 3 with temporary PMDs). The median overlap volumes between CSTs with yellow, blue, and white TDT lines in patients with any PMD (temporary or permanent) were 1.15, 0.68, and 0.41 cm3, respectively. The overlap volumes and surface areas revealed significant differences in those with PMDs and those with no deficits (p = 0.0019 and 0.003, 0.012 and 0.0012, and 0.001 and 0.005 for the yellow, blue, and white TDT lines, respectively). The receiver operating characteristic was used to select the optimal cutoff point of the overlapped volumes and areas. Cutoff points for overlap volumes and areas based on optimal sensitivity (92%–100%) and specificity (80%–90%) were 0.103, 0.068, and 0.046 cm3 and 0.15, 0.07, and 0.11 mm2 for the yellow, blue, and white TDT lines, respectively.

CONCLUSIONS

Even a minimal overlap between the TDT lines and CSTs can cause a PMD after LITT. Precise planning and avoidance of critical structures and important white matter fibers should be considered when treating deep-seated tumors.

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Mayur Sharma, Ashish Sonig, Sudheer Ambekar and Anil Nanda

Object

The aim of this study was to analyze the incidence of adverse outcomes and inpatient mortality following resection of intramedullary spinal cord tumors by using the US Nationwide Inpatient Sample (NIS) database. The overall complication rate, length of the hospital stay, and the total cost of hospitalization were also analyzed from the database.

Methods

This is a retrospective cohort study conducted using the NIS data from 2003 to 2010. Various patient-related (demographic categories, complications, comorbidities, and median household income) and hospital-related variables (number of beds, high/low case volume, rural/urban location, region, ownership, and teaching status) were analyzed from the database. The adverse discharge disposition, in-hospital mortality, and the higher cost of hospitalization were taken as the dependent variables.

Results

A total of 15,545 admissions were identified from the NIS database. The mean patient age was 44.84 ± 19.49 years (mean ± SD), and 7938 (52%) of the patients were male. Regarding discharge disposition, 64.1% (n = 9917) of the patients were discharged to home or self-care, and the overall in-hospital mortality rate was 0.46% (n = 71). The mean total charges for hospitalization increased from $45,452.24 in 2003 to $76,698.96 in 2010. Elderly patients, female sex, black race, and lower income based on ZIP code were the independent predictors of other than routine (OTR) disposition (p < 0.001). Private insurance showed a protective effect against OTR disposition. Patients with a higher comorbidity index (OR 1.908, 95% CI 1.733–2.101; p < 0.001) and with complications (OR 2.214, 95% CI 1.768–2.772; p < 0.001) were more likely to have an adverse discharge disposition. Hospitals with a larger number of beds and those in the Northeast region were independent predictors of the OTR discharge disposition (p < 0.001). Admissions on weekends and nonelective admission had significant influence on the disposition (p < 0.001). Weekend and nonelective admissions were found to be independent predictors of inpatient mortality and the higher cost incurred to the hospitals (p < 0.001). High-volume and large hospitals, West region, and teaching hospitals were also the predictors of higher cost incurred to the hospitals (p < 0.001). The following variables (young patients, higher median household income, nonprivate insurance, presence of complications, and a higher comorbidity index) were significantly correlated with higher hospital charges (p < 0.001), whereas the variables young patients, nonprivate insurance, higher median household income, and higher comorbidity index independently predicted for inpatient mortality (p < 0.001).

Conclusions

The independent predictors of adverse discharge disposition were as follows: elderly patients, female sex, black race, lower median household income, nonprivate insurance, higher comorbidity index, presence of complications, larger hospital size, Northeast region, and weekend and nonelective admissions. The predictors of higher cost incurred to the hospitals were as follows: young patients, higher median household income, nonprivate insurance, presence of complications, higher comorbidity index, hospitals with high volume and a large number of beds, West region, teaching hospitals, and weekend and nonelective admissions.

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Mayur Sharma, Daria Krivosheya, Hamid Borghei-Razavi, Gene H. Barnett and Alireza M. Mohammadi

Laser interstitial thermal therapy (LITT) is a minimally invasive stereotactic technique that causes tumor ablation using thermal energy. LITT has shown to be efficacious for the treatment of deep-seated brain lesions, including those near eloquent areas. In this video, the authors present the case of a 62-year-old man with a history of metastatic melanoma who presented with worsening right-sided hemiparesis. MRI revealed a contrast-enhancing lesion in left centrum semiovale in close proximity to corticospinal tracts, consistent with radiation necrosis. The authors review their stepwise technique of LITT with special attention to details for a lesion located near eloquent area.

The video can be found here: https://youtu.be/ndrTgi6MXqE.

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Bryony A. J. Dayment and Oliver D. Ingham Clark